Low-Grade systemic inflammation is associated with domain-specific cognitive performance and cognitive decline in older adults: Data from the TUDA study

Studies examining the relationships between chronic inflammation, cognitive function and cognitive decline in older adults have yielded conflicting results. In a large cohort of older adults free from established dementia (n = 3270; 73.1 ± 7.9 years; 68.4% female), we evaluated the cross-sectional and longitudinal relationships between serum cytokines (IL-6, IL-10, TNF-α) and both global and domain-specific cognitive performance (Repeatable Battery for Assessment of Neuropsychological Status [RBANS]). Higher IL-6 (OR: 1.33; 1.06, 1.66, p = 0.01), TNF-α (OR: 1.35; 1.09, 1.67, p = 0.01) and IL-6:IL-10 Ratio (OR: 1.43; 1.17, 1.74, p = 0.001) were cross-sectionally associated with impaired global RBANS performance. For specific cognitive domains, greatest effect sizes were observed between higher TNF-α levels and poorer visual-spatial and attention performance. In a subset of participants (n = 725; 69.8 ± 5.5 years; 67.0% female) with repeat assessment performed at a median of 5.4 years, only higher baseline IL-6:IL-10 ratio was associated with impaired incident overall, immediate memory and visual-spatial performance. Associations were stronger in females, but not modified by age or APOE genotype.

72 SEASONAL VARIATION IN HYPERPARATHYROIDISM IN OLDER IRISH ADULTS

Background

Vitamin D deficiency is common in Ireland, varies by season and can result in secondary hyperparathyroidism. High Parathyroid Hormone (PTH) levels due to low vitamin D status are associated with increased bone turnover and lower bone mineral density, especially at cortical sites such as the hip. Given the variation in vitamin D status by time of year, our study aimed to examine for seasonal differences in hyperparthyroidism in older adults.

Methods

Study participants were from a large cross-sectional study of older Irish adults recruited from hospital outpatient services and GP practices. Exclusion criteria were: eGFR< 30ml/min and elevated serum calcium (>2.5 mmol/l) in order to avoid primary hyperparathyroidism or elevated serum PTH due to advanced renal impairment. Hyperparathyroidism was defined as a PTH level > 65 ng/ml. The relationship between hyperparathyroidism and season was examined in regression models adjusting for potential factors affecting PTH.

Results

There were 4324 participants, mean age 73.8 +/- 7.9 years, 65.4% were female. Hyperparathyroidism was more prevalent in Spring versus Autumn (17.4 vs 11.4 %, P = 0.0002). The increased prevalence remained after adjusting for age, gender, body mass index, timed up and go, dairy intake, eGFR, and smoking (OR 1.6, 1.2- 2.0, P=0.0003). This also corresponded to the seasonal variation in vitamin D status with deficiency (25(OH)D < 30 nmol/l) highest in Spring (23.3%) and lowest in Autumn (16.8%).

Conclusion

We found that hyperparathyroidism fluctuates with season in an inverse relationship with vitamin D. Overall, high PTH levels were 60% more likely in Spring versus Autumn. This emphasises the importance of maintaining adequate vitamin D status all year round. While we adjusted for dairy intake, we did not have accurate measures of total dietary calcium intake which could also vary seasonally and be a contributory factor.

51 VITAMIN D DEFICIENCY IS ASSOCIATED WITH INCREASED RISK OF ATRIAL FIBRILLATION: A CROSS-SECTIONAL ANALYSIS

Background

Atrial Fibrillation (AF) is prevalent (up to 10.9%) in Irish adults aged over 65 and significantly increases stroke risk, as well as being associated with greater stroke severity. Identifying potential contributing factors to development of AF offers opportunity for AF prevention and reduction in associated morbidity. Low vitamin D status has been associated with AF but studies are inconsistent. We aimed to assess the potential relationship between vitamin D deficiency and self-reported AF in older Irish adults.

Methods

Participants were from a large cross-sectional study of Irish adults aged >60 years, recruited from hospital outpatient services and GP practises. The diagnosis of AF was based on self-report so those with a Mini Mental State Examination (MMSE) <25 were excluded. Vitamin D deficiency was defined as a 25(OH)D <30 nmol/l. The relationship between deficiency and AF was explored in regression models.

Results

4264 participants, mean age 73.1± 8.0 years, female (67.4%) and 11.9% had AF. There was a higher prevalence of AF in those who were deficient vs non-deficient (17.2% vs 10.9%, P<0.0001). In a subsample (n = 4043), increased risk remained after adjusting for age, gender, season, vitamin D supplement use, body mass index, timed up and go, alcohol intake, smoking status, hypertension, diabetes, and heart disease (coronary artery disease and/or heart failure) (OR: 1.3, 1.1- 1.7 , P =0.023).

Conclusion

We identified that vitamin D deficiency was independently associated with a 30% increased likelihood of self-reported AF in older adults. Vitamin D is known to inhibit the renin angiotensin, aldosterone system which may play a role in both structural and electrical remodelling of the atrium. It may also have anti-inflammatory properties which could protect against AF. We were not able to distinguish between valvular and non-valvular AF though findings offer an interesting insight for potential further investigation.

73 PREVALENCE OF SECONDARY HYPERPARATHYROIDISM BY VITAMIN D STATUS IN OLDER IRISH ADULTS

Background

Secondary hyperparathyroidism commonly results from vitamin D deficiency and can lead to accelerated bone turnover and bone loss, especially at cortical sites like the hip. It can also attenuate the response to antiresorptive treatments used for osteoporosis. However, several factors may influence PTH response. We aimed to identify the prevalence of secondary hyperparathyroidism by categories of vitamin D status in older Irish adults attending a bone health clinic.

Methods

The study population consisted of older adults (aged over 60 years) attending a bone health clinic at a large hospital. Participants with a serum calcium >2.5 mmol/l and eGFR <30 ml/min were excluded to avoid cases of primary hyperparathyroidism or elevated serum PTH due to advanced renal disease. Hyperparathyroidism was defined as a serum PTH > 65 pg/ml. 25 hydroxyvitamin D (25(OH)D) was measured with liquid chromatography mass spectroscopy.

Results

There were 800 cases identified, mean age 72.9 +/- 7.9 years, and 85.3% were female. The prevalence of secondary hyperparathyroidism by 25(OH)D categories were 28.1% (<30nmol/l), 17.4% (30-49.9 nmol/l) and 8.0% (50-74 nmol/l). Older age (P < 0.03) and lower eGFR (P = 0.01) were associated with hyperparathyroidism independent of vitamin D status.

Conclusion

Nearly one-third of patients who were vitamin D deficient (<30 nmol/L) and one-sixth who were insufficient (30-49.9 nmol/l) had hyperparathyroidism, similar to the results of other studies. However, hyperparathyroidism was also observed in 8% of those with 25(OH)D levels between 50 -74 nmol/l, suggesting that higher levels i.e. ≥ 75 nmol/l may be preferable in older adults. Lower eGFR and older age were also independently associated with higher PTH, consistent with previous research. Higher dietary and supplemental calcium intake is also known to suppress PTH response, though we were not able to account for this in our study.

17 CROSS-SECTIONAL AND LONGITUDINAL RELATIONSHIPS BETWEEN MOBILITY, NEUROPSYCHOLOGICAL PERFORMANCE AND FALLS IN COMMUNITY-DWELLING OLDER ADULTS: DATA FROM TUDA

Background

Impaired mobility is associated with incident cognitive impairment and dementia. However, the complex bi-directional temporal relationships between subtle impairments in neuropsychological performance, mobility trajectories and falls is poorly understood.

Methods

Using data from the Trinity, Ulster Department of Agriculture (TUDA/TUDA5+) study, we evaluated cross-sectional and longitudinal relationships between impaired mobility, neuropsychological performance and falls using regression models adjusted for important clinical confounders. Older adults with potential cognitive impairment (Mini-Mental State Examination score <25) were excluded. Detailed neuropsychological assessment was performed using the RBANS (Repeatable Battery for Neuropsychological Assessment) and FAB (Frontal Assessment Battery). Impaired mobility was assessed using Irish population-specific age/sex/height-specific Timed-Up-and-Go (TUG) cut-offs.

Results

Of 4,103 participants (72.9 ± 7.9 years; 67.4% female), just under one-fifth (17.5%) met criteria for impaired mobility. Older adults with impaired mobility had significantly greater likelihood of impaired neuropsychological performance, in particular for language (OR 1.77; 1.35-2.31; p<0.001) and attention (OR 1.69; 1.37-2.08; p<0.001) domains. In 953 participants followed for a median 5.2 (IQR: 4.83-7.26) years, impaired mobility at baseline significantly predicted incident impairment in immediate memory (OR 2.56; 1.33-4.95; p<0.001). Stronger relationships were seen for impaired neuropsychological performance predicting mobility decline rather than impaired mobility predicting cognitive decline (all p<0.001). Both impaired mobility and neuropsychological performance were associated with incident falls, particularly for impairments in executive function and attention (all p<0.001). Impaired mobility in isolation had poor performance as a sole test to predict incident cognitive impairment (AUC: 0.55-0.65).

Conclusion

In both cross-sectional and longitudinal analyses, impaired mobility is associated with subtle impairments in neuropsychological performance. Whilst impaired neuropsychological performance was a greater predictor of impaired mobility rather than vice versa, our findings highlight the complex relationship between mobility and cognitive trajectories in older adults, emphasising the need for comprehensive cognitive and falls assessment in those presenting with new-onset subtle impairments in mobility and cognition.

261 HIGH FRACTURE RISK IN OLDER IRISH ADULT FALLERS

Background

Fracture risk due to falls depends on several factors including bone density, quality and size, hip geometry (axis length), direction of fall (forward, backwards or sideways), body mass index (BMI), type of surface impacted, body site of impact and mechanism of fall (eg syncope). We aimed to identify the fracture risk per fall in frail older Irish adults.

Methods

Participants were from the hypertensive and cognitive cohort of the Trinity, Ulster, Dept Agriculture (TUDA) study of Irish adults (aged >60) recruited from hospital outpatient services and GP practises. Falls and falls resulting in fracture in the previous year were self-reported so those with an MMSE < 25 were excluded to avoid recall bias. We identified fallers, recurrent fallers and fractures due to falls in the previous year.

Results

892 fallers, mean age 76.3 ± 8.4 yrs, 65.2% female. 23.8% had 2 falls and 24.2% ≥3 falls. Mean timed up and go was 17.3 ± 9.5 seconds. Commonest fracture due to falls were hip (20.1%), upper limb (18.5%) and lower limb (17.9%) with one fracture of neck and skull. Fracture rate per fall was 7.1%: 1.7% for hip, 1.3% for lower and 1.2% for upper limb. Annual fracture rate per faller was 16.5%. The only predictors of fall with fracture versus no fracture were female sex (OR 2.4, 1.6-3.6, P<0.001) and lower body mass index (P=0.001).

Conclusion

We identified similar hip fracture rates (1.7%) due to falls as in other studies. However, one in six fallers had sustained a fracture in the previous year reflecting the high proportion of recurrent fallers. Lower BMI and female sex predicted fall with fracture as both are strongly correlated with risk of osteoporosis. Recent guidelines now factor in recurrent falls when estimating the probability of future osteoporotic fractures.

126 CENTRAL ADIPOSITY IS ASSOCIATED WITH INCREASED PREVALENCE OF VERTEBRAL FRACTURES

Background

Increased body weight and obesity are associated with greater bone mineral density (BMD) though effects on fracture risk appear to be site specific. In particular, the relationship between Body Mass Index (BMI), abdominal weight and Vertebral Fractures (VF) is complex. Some studies have found greater incidence of VF's with obesity though results are inconsistent. Recent evidence supports a stronger association between measures of abdominal fat and VF's. We aimed to examine the association between central adiposity and VF's in older Irish adults.

Methods

Participants were from a large cross-sectional study of older Irish adults (aged >60) attending GP or hospital outpatient services. VF diagnosis was based on self-report (ie. clinical vertebral fracture) so we excluded those with a Mini Mental State Examination (MMSE) < 25. BMD was measured with DXA and patients taking antiresorptive or anabolic therapies were excluded. The relationship of waist hip ratio (a surrogate marker of central adiposity) with VF's was explored in regression models.

Results

2055 identified, mean age 69.8 ± 6.3 years (range 60-99), 58.6% female. Vertebral fracture prevalence was 6.3% (n=130). Waist hip ratio was positively associated with presence of a vertebral fracture after adjusting for age, sex, BMI, timed up and go, smoking, serum vitamin D, lumbar spine BMD and steroid use > 3 months (beta: 0.04, P<0.001).

Conclusion

We identified that central adiposity (as measured by waist/hip ratio) was associated with VF presence independent of several factors including BMI and spine BMD. This suggests that body fat distribution and/or altered bone quality may play a role. Visceral body fat (which is correlated with waist hip ratio) is associated with increased production of adipocytokines, altered vertebral geometry and micro-architecture, increased vertebral bone marrow fat and greater loading forces on the spine, all of which may mediate increased VF risk.

Reduced kidney function is associated with poorer domain-specific cognitive performance in community-dwelling older adults

OBJECTIVES

Whilst chronic kidney disease has been associated with cognitive impairment, the association between reduced estimated Glomerular Filtration Rate (eGFR) and domain-specific cognitive performance is less clear and may represent an important target for the promotion of optimal brain health in older adults.

METHODS

Participants aged >60 years from the Trinity-Ulster-Department of Agriculture study underwent detailed cognitive assessment using the Mini-Mental State Examination (Mini-Mental State Examination (MMSE)), Frontal Assessment Battery (FAB) and Repeatable Battery for Assessment of Neuropsychological Status (RBANS). Poisson and linear regression models assessed the relationship between eGFR strata and cognitive performance.

RESULTS

In 4887 older adults (73.9 ± 8.3 years; 67.7% female), declining eGFR strata was associated with greater likelihood of error on the MMSE/FAB and poorer overall performance on the RBANS. Following robust covariate adjustment, findings were greatest for GFR <45 ml/ml/1.73 m² (Incidence Rate Ratio: 1.17; 95% CI 1.08, 1.27; p < 0.001 for MMSE; IRR: 1.13; 95% CI 1.04, 1.13; p < 0.001 for FAB; β: -3.66; 95% CI -5.64, -1.86; p < 0.001 for RBANS). Additionally, eGFR <45 ml/ml/1.73 m² was associated with poorer performance on all five RBANS domains, with greatest effect sizes for immediate memory, delayed memory and attention. Associations were strongest in those aged 60-70, with no associations observed in those >80 years.

CONCLUSIONS

Reduced kidney function was associated with poorer global and domain-specific neuropsychological performance. Associations were strongest with eGFR <45 ml/min/1.73 m² and in those aged 60-70 years, suggesting that this population may potentially benefit from potential multi-domain interventions aimed at promoting optimal brain health in older adults.

Associations of atrophic gastritis and proton-pump inhibitor drug use with vitamin B-12 status, and the impact of fortified foods, in older adults

BACKGROUND

Atrophic gastritis (AG) and use of proton pump inhibitors (PPIs) result in gastric acid suppression that can impair the absorption of vitamin B-12 from foods. The crystalline vitamin B-12 form, found in fortified foods, does not require gastric acid for its absorption and could thus be beneficial for older adults with hypochlorhydria, but evidence is lacking.

OBJECTIVES

To investigate associations of AG and PPI use with vitamin B-12 status, and the potential protective role of fortified foods, in older adults.

METHODS

Eligible participants (n = 3299) not using vitamin B-12 supplements were drawn from the Trinity-Ulster and Department of Agriculture cohort, a study of noninstitutionalized adults aged ≥60 y and recruited in 2008-2012. Vitamin B-12 status was measured using 4 biomarkers, and vitamin B-12 deficiency was defined as a combined indicator value < -0.5. A pepsinogen I:II ratio <3 was considered indicative of AG.

RESULTS

AG was identified in 15% of participants and associated with significantly lower serum total vitamin B-12 (P < 0.001) and plasma holotranscobalamin (holoTC; P < 0.001), and higher prevalence of vitamin B-12 deficiency (38%), compared with PPI users (21%) and controls (without AG and nonusers of PPIs; 15%; P < 0.001). PPI drugs were used (≥6 mo) by 37% of participants and were associated with lower holoTC concentrations, but only in participants taking higher doses (≥30 mg/d). Regular, compared with nonregular, consumption of fortified foods (i.e., ≥5 and 0-4 portions/wk, respectively) was associated with higher vitamin B-12 biomarkers in all participants, but inadequate to restore normal vitamin B-12 status in those with AG.

CONCLUSIONS

Older adults who have AG and/or use higher doses of PPIs are more likely to have indicators of vitamin B-12 deficiency. Fortified foods, if consumed regularly, were associated with enhanced vitamin B-12 status, but higher levels of added vitamin B-12 than currently provided could be warranted to optimize status in people with AG.

Hyperglycemia and Metformin Use Are Associated With B Vitamin Deficiency and Cognitive Dysfunction in Older Adults

CONTEXT

Emerging evidence suggests that deficiencies of folate-related B vitamins can arise with metformin treatment and are independently linked with cognitive dysfunction, a comorbidity of diabetes.

OBJECTIVE

To determine the impact of hyperglycemia and metformin use on relevant B vitamin biomarkers and cognitive outcomes in older adults.

SETTING AND PARTICIPANTS

Community-dwelling older adults (74.1 ± 8.3 years, n = 4160) without dementia, recruited to the Trinity, Ulster and Department of Agriculture cohort study in 2008 to 2012, were classified as normoglycemic (n = 1856) or hyperglycemic, based on HbA1c ≥5.7% (39 mmol/mol), either with (n = 318) or without (n = 1986) metformin treatment.

MAIN OUTCOME MEASURES

Biomarkers of folate, vitamin B12, vitamin B6, and riboflavin were measured. Cognitive assessments included the Repeatable Battery for Assessment of Neuropsychological Status (RBANS) and the Frontal Assessment Battery (FAB).

RESULTS

Metformin use was associated with higher risk of deficiency of vitamin B12 (combined B12 index ≤-1; OR 1.45; 95% CI, 1.03 to 2.02) and vitamin B6 (plasma pyridoxal 5-phosphate <30.0 nmol/L; OR 1.48; 95% CI, 1.02 to 2.15). Fortified foods when eaten regularly had a positive impact on all relevant B vitamin biomarkers, even with hyperglycemia. After adjustment for relevant covariates, metformin use was associated with an increased risk of cognitive dysfunction as assessed with the RBANS (OR 1.36; 95% CI, 1.03 to 1.80) and FAB (OR 1.34; 95% CI, 1.03 to 1.74).

CONCLUSIONS

Use of metformin by older adults is associated with poorer cognitive performance; B vitamin deficiency may be implicated. Fortified foods can optimize B vitamin status and may be beneficial for maintaining better cognitive health in older people with or at risk for diabetes.

Riboflavin and vitamin B-6 intakes and status and biochemical response to riboflavin supplementation in free-living elderly people

Free-living elderly people aged > or = 65 y were recruited to assess riboflavin and vitamin B-6 intakes and status and the effect of riboflavin supplementation on biochemical indicators of these 2 vitamins. The status of riboflavin (erythrocyte glutathione reductase activation coefficient; EGRAC) and vitamin B-6 (plasma pyridoxal-5'-phosphate; PLP) were determined in a total sample of 92 subjects, from whom dietary intake data were obtained by using the diet history method (n = 83). Although dietary intakes of both vitamins were considered to be adequate according to current reference values, abnormal EGRAC and plasma PLP values were identified in 49% and 38% of subjects, respectively, with 21% having suboptimal status for both nutrients. A subgroup of subjects from the initial sample (n = 45) was assigned in a double-blind manner to receive either 1.6 or 25 mg riboflavin or placebo daily for 12 wk. In those subjects with a baseline EGRAC or plasma PLP value falling outside the currently accepted threshold value for adequacy, low-dose riboflavin supplementation improved status of the limiting nutrient significantly (P<0.0001 and P = 0.020 for EGRAC and plasma PLP responses, respectively). We conclude that a high proportion of healthy elderly people may have suboptimal status for these nutrients despite apparently adequate dietary intakes. Furthermore, we showed that riboflavin supplementation at physiologic doses corrects biochemical abnormalities of not only EGRAC, but also plasma PLP, confirming the biochemical interdependency of these vitamins and suggesting that riboflavin is the limiting nutrient.

A prospective study of the process of assessment and care management in the discharge of elderly patients from hospital

Assessment and care management (ACM) of elderly patients prior to discharge from hospital has been in place since 1993. It involves a complex multi-disciplinary assessment of needs which may delay discharge from hospital. We prospectively studied the process of ACM in a group of patients discharged from hospital over a three month period. The times taken for completion of the necessary reports, and any delays in the process were recorded. The times of each individual step in the process were correlated to overall length of stay and to the length of the care management process. The effect of intercurrent illnesses or other delays was studied. Of the available sample (n = 83), 16 patients died and two required long term hospital care. The median length of stay of the remainder (n = 65) was 36 days (range 5-149 days). The median time from the start of the ACM process to discharge was 22 days (0-89 days). The strongest correlation with total length of stay was the time from admission until ACM commenced (rho = 0.661, p < 0.0001). The time spent in the ACM process was related strongly to the time taken for the Care Manager to process the applications (rho = 0.682, p < 0.0001). Delay was recorded in 17 (24%) cases, resulting in an increased length of stay (p < 0.001). While care management may help in appropriate placement after hospital discharge, these results suggest that it is prone to delays outside the hospital setting. Such delays result in patients waiting in hospital for care packages to be set up in the community. This has implications for acute hospital services.

Comparison of nursing home residents admitted from home or hospital

A growing elderly population coupled with a reduction in hospital long term care has led to an increase in the independent nursing home sector. This is an expensive resource. Proper placement is therefore essential to ensure its efficient use. Prior to the introduction of care management there was no standard assessment procedure for admission to nursing home care from different sources. A nursing home population (n = 624) in North and West Belfast was studied and mental scores, levels of disability, and the source of admission to the nursing home recorded. Residents admitted from geriatric medical units (n = 132) were compared with those from general medical and surgical wards (n = 168) and those from home (n = 243). Residents who were admitted from a geriatric unit were the most disabled, those admitted from home were the least and those from general wards had intermediate levels of disability (p < 0.005). This is likely to be the result of different assessment procedures for prospective nursing home residents. With the introduction of care management, it is hoped that standardised assessment will follow. The roles of different medical specialists in this process is not yet clear. Further study is needed to assess the appropriateness of placement in nursing homes under care management.

Hyperglycaemia and mortality from acute stroke

Hyperglycaemia has been observed after acute stroke, and is associated with a poor prognosis. It is not known whether this is due to the stress response of the acute illness or whether hyperglycaemia is, in itself, harmful to ischaemic nervous tissue. Seventy-one patients admitted to hospital with acute stroke and no history of diabetes or other acute illness were recruited, and fasting blood sampling was carried out within 24 h of symptom onset, for plasma glucose and stress hormones and levels of haemoglobin A1c (HbA1c). Computerized tomography of the brain was carried out on 77% of the subjects. The subjects were followed up for 3 months or until death. Glucose levels were higher in subjects who died during the course of the study (p = 0.025), but this relationship became non-significant after age (p < 0.001) and cortisol (p = 0.001) levels were taken into account with multivariate analysis. The correlation between serum cortisol and the volume of the lesion on CT scan was also stronger than the relation of glucose with volume. Haemoglobin A1c had no relationship with either mortality or lesion volume. These findings suggest that the hyperglycaemia seen after an acute stroke is secondary to a stress response and they do not support the theory of hyperglycaemia being harmful to ischaemic nervous tissue. These findings have implications for the treatment of acute stroke with hypoglycaemic agents.